MusculoSkeletal Exam

Anterior talofibular ligament

Figure 13.30 Palpation of the anterior talofibular ligament.

Posterior Talofibular Ligament

The posterior talofibular ligament runs from the lateral malleolus to the posterior tubercle of the talus. The ligament is very strong and deep. It is not palpable.

Peroneus Longus and Brevis Tendons

Place your fingers posterior and slightly inferior to the lateral malleolus. You will find the tendons of the peroneus longus and brevis. The brevis is closer to the malleolus and the longus is just posterior to the malleolus. The tendon is made more distinct by asking the patient to evert the foot (Figure 13.32). You can visualize the tendon of the peroneus brevis distally to its attachment on the base of the fifth metatarsal. A tender thickening that is palpable inferior to the lateral malleolus may be indicative of stenosing tenosynovitis of the common peroneal tendon sheath.

Painful snapping of the tendons can occur if they sublux anteriorly to the lateral malleolus.

Posterior Aspect

Bony Structures

Calcaneus

The large dome of the calcaneus is easily palpable at the posterior aspect of the foot. You will notice that the calcaneus becomes wider as you approach the base

(Figure 13.33). Excessive prominence of the superior

Calcaneofibular ligament

Figure 13.31 Palpation of the calcaneofibular ligament.

Peroneus brevis

Peroneus longus

Figure 13.32 Palpation of the peroneus longus and brevis.

tuberosity of the calcaneus often occurs in women who wear high heels and has been called a pump bump.

Soft-Tissue Structures

Tendocalcaneus (Achilles Tendon)

Place your fingers at the posterior aspect of the calcaneus and move them proximally to the lower one-third of the calf. Palpate the thick common tendon of the gastrocnemius and soleus, referred to as the Achilles tendon (Figure 13.34). Tenderness may be noted if the patient has overused the muscle and has developed a tenosynovitis. Swelling may be noted and crepitus can be perceived with movement. The tendon can be ruptured secondary to trauma. Discontinuity of the tendon can be tested clinically (see p. 423). Palpation of the disruption of the tendon may be difficult because of the secondary swelling. The patient will be unable to actively plantarflex the ankle.

Retrocalcaneal Bursa

The retrocalcaneal bursa separates the posterior aspect of the calcaneus and the overlying Achilles tendon. It is not normally palpable unless it is inflamed from increased friction (Figure 13.35).

Calcaneal Bursa

The calcaneal bursa separates the distal attachment of the tendocalcaneus and the overlying skin. This bursa is not normally palpable (Figure 13.36).

If thickness, tenderness, or edema is noted in the posterior calcaneal area, the patient may have bursitis. The calcaneal bursa is often irritated by wearing improperly fitting shoes that rub against the posterior aspect of the foot.

Plantar Surface

Bony Structures

Medial Tubercle of the Calcaneus

Place your fingers on the plantar surface of the calcaneus and move them anteriorly to the dome. You will feel a flattened area that is not very distinct. You can confirm your location by abducting the great toe and palpating the attachment of the abductor hallucis. If you move medially, you will feel the attachments of the flexor digitorum brevis and the plantar aponeurosis (Figure 13.37). The medial tubercle bears weight and is the site of the development of heel spurs. If a spur is present, the tubercle will be very tender to palpation.

The most common cause of a spur is chronic plantar fasciitis.

Sesamoid Bones

Find the lateral aspect of the first metatarsophalangeal joint and allow your fingers to travel to the inferior aspect. You will feel two small sesamoid bones when you press superiorly on the ball of the foot. These sesamoid bones are located in the tendon of the flexor hallucis brevis and help to more evenly distribute weight-bearing forces (Figure 13.38). The sesamoid bones will also facilitate the function of the flexor hallucis brevis, especially during toe off.

Metatarsal Heads

Allow your fingers to travel slightly proximally from the inferior portion of the first metatarsophalangeal joint until you feel the first metatarsal head. Move laterally and palpate the heads of metatarsals two through five (Figure 13.39). You should feel that the first and fifth metatarsal heads are the most prominent because of the shape of the transverse arch of the foot (Figure 13.40). Sometimes you will notice a drop of the second metatarsal head, which will increase the weight-bearing surface. You will also palpate increased callus formation in this area. Tenderness and swelling between the metatarsals may be indicative of a neuroma. Morton’s neuroma is the most common neuroma and is usually found between the third and fourth metatarsals.

Figure 13.39 Palpation of the metatarsal heads.

Soft-Tissue Structures

Plantar Aponeurosis (Plantar Fascia)

The plantar aponeurosis consists of strong longitudinal fibers that run from the calcaneus and divide into five processes before attaching onto the metatarsal heads. The plantar aponeurosis plays an integral part in the support of the medial longitudinal arch (Figure 13.41). Focal tenderness and nodules on the plantar surface may be indicative of plantar fasciitis. Under normal

Transverse arch

Figure 13.40 Transverse arch of the foot.

Plantar aponeurosis

Figure 13.41 Palpation of the plantar aponeurosis (plantar fascia).

Chapter 13 The Ankle and Foot

circumstances the plantar surface should be smooth and without any nodules. It should not be tender to palpation.

Toes

Under normal circumstances the toes should be flat and straight. The great toe should be longer than the second. If the second toe is longer it is referred to as a Morton’s toe (Figure 13.42) and is due to a short first metatarsal. Observe the toes for alignment, callus or corn formation, color, and temperature. Calluses and corns can be found on top of the joint surfaces, beneath the toes and between them.

Claw Toes

The patient will present with hyperextension of the metatarsophalangeal joints and flexion of the proximal and distal interphalangeal joints (Figure 13.43). The patient will often have callus formation over the dorsal aspect of the toes. This is caused by rubbing from the patient’s shoes due to decreased space that results from the deformity. Calluses will also be noted at the tip of the toes because of the increased amount of distal weight-bearing. Patients with pes cavus often develop claw toes.

Morton's toe

Figure 13.42 Morton’s toe.

Hammer Toes

The patient will present with hyperextension of the metatarsophalangeal joint, flexion of the proximal interphalangeal joint, and hyperextension of the distal interphalangeal joint (Figure 13.44). The patient will often have callus formation over the dorsal aspect of the proximal interphalangeal joint secondary to increased pressure from the top of the shoe.

Active Movement Testing

Active movement tests should be quick, functional tests designed to clear the joint. They are designed to help you see if the patient has a gross restriction. You should always remember to compare the movement from one side to the other. If the motion is pain free at the end of the range, you can add an additional overpressure to “clear” the joint. If the patient experiences pain in any of these movements, you should continue to explore whether the etiology of the pain is secondary to contractile or noncontractile structures by using passive and resistive testing.

Active movements of the ankle and foot should be performed in both weight-bearing and non-weight- bearing (supine or long sitting) positions. In the weight-bearing position, instruct the patient to stand and walk on the toes to check for plantar flexion and toe flexion, and to stand and walk on the heels to test for dorsiflexion and toe extension. Then instruct the patient to stand on the lateral border of the foot to test for inversion, and then the medial border of the foot to test for eversion (Figure 13.45).

In the non-weight-bearing position, instruct the patient to pull the ankle up as far as possible, push it down, and turn it in and then out. This will check for dorsiflexion, plantar flexion, inversion, and eversion.

Then have the patient bring up the toes, curl them, and spread them apart. This will check for toe extension, flexion, abduction, and adduction (Figure 13.46).

Passive Movement Testing

Passive movement testing can be divided into two areas: physiological movements (cardinal plane), which are the same as the active movements, and mobility testing

Chapter 13 The Ankle and Foot

of the accessory movements (joint play, component). You can determine whether the noncontractile (inert) elements are causative of the patient’s problem by using these tests. These structures (ligaments, joint capsule, fascia, bursa, dura mater, and nerve root) (Cyriax, 1979) are stretched or stressed when the joint is taken to the end of the available range. At the end of each passive physiological movement, you should sense the end feel and determine whether it is normal or pathological. Assess the limitation of movement and see if it fits into a capsular pattern. The capsular patterns of the foot and ankle are as follows: talocrural jointagreater restriction of plantar flexion than dorsiflexion; subtalar jointagreater restriction of varus than valgus; midtarsal jointamost restriction in dorsiflexion, followed by plantar flexion, adduction, and medial rotation; first metatarsophalangeal joint agreater restriction of extension than flexion; interphalangeal jointsagreater restriction of extension than flexion (Kaltenborn, 1999; Magee, 1997).

Physiological Movements

You will be assessing the amount of motion available in all directions. Each motion is measured from the anatomical starting position. In the talocrural joint this is when the lateral aspect of the foot creates a right angle with the longitudinal axis of the leg. In addition, a line passing through the anterior superior iliac spine and through the patella must be aligned with the second toe. The starting position for the toes is when the longitudinal axes through the metatarsals form a straight line with the corresponding phalanx.

Dorsiflexion

You can measure dorsiflexion with the patient either in the sitting position with the leg dangling over the side of the treatment table or in the supine position.

This motion takes place in the talocrural joint. Place the patient so that the knee is flexed at 90 degrees and the foot is at 0 degree of inversion and eversion. Place one hand over the distal posterior aspect of the leg to stabilize the tibia and fibula and prevent movement at the knee and hip. Place your other hand with the palm flattened under the plantar surface of the foot directing your fingers toward the toes. Bend the ankle in a cranial direction. The normal end feel is abrupt and firm (ligamentous) because of the tension from the tendocalcaneus and the posterior ligaments (Kaltenborn, 1999; Magee, 1997). The normal range

Figure 13.47 Passive movement testing of dorsiflexion.

of motion is 0–20 degrees (Figure 13.47) (American Academy of Orthopedic Surgeons, 1965).

Plantar Flexion

You can measure plantar flexion with the patient either in the sitting position with the leg dangling over the side of the treatment table or in the supine position. This motion takes place in the talocrural joint. Place the patient so that the knee is flexed at 90 degrees and the foot is at 0 degree of inversion and eversion. Place one hand over the distal posterior aspect of the leg to stabilize the tibia and fibula and prevent movement at the knee and hip. Place your other hand with the palm flattened over the dorsal surface of the foot directing your fingers laterally. Push the foot in a caudal direction avoiding any inversion or eversion. The normal end feel is abrupt and firm (ligamentous) because of the tension in the anterior capsule and the anterior ligaments (Kaltenborn, 1999; Magee, 1997). A hard end feel may result from contact between the posterior talar tubercle and the posterior aspect of the tibia. The normal range of motion is 0–50 degrees (Figure 13.48) (American Academy of Orthopedic Surgeons, 1965).

Inversion

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the

Figure 13.48 Passive movement testing of plantar flexion.

knee flexed to 90 degrees or in the supine position with the foot over the end of the treatment table. Make sure that the hip is at 0 degree of rotation, and adduction and abduction. Inversion, which is a combination of supination, adduction, and plantar flexion, takes place at the subtalar, transverse tarsal, cuboideonavicular, cuneonavicular, intercuneiform, cuneocuboid, tarsometatarsal, and intermetatarsal joints. Place one hand over the distal medial and posterior aspect of the leg to stabilize the tibia and fibula and prevent movement at the knee and hip. Place your hand over the distal lateral aspect of the foot with your thumb on the dorsal surface and the other four fingers under the metatarsal heads. Turn the foot in a medial and superior direction. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsules and the lateral ligaments (Kaltenborn, 1999; Magee, 1997). The normal range of motion is 0–35 degrees (Figure 13.49) (American Academy of Orthopedic Surgeons, 1965).

Eversion

Place the patient in the sitting position with the leg dangling over the side of the treatment table and the knee flexed to 90 degrees or in the supine position

with the foot over the end of the treatment table. Make sure that the hip is at 0 degrees of rotation, and adduction and abduction. Eversion, which is a combination of pronation, abduction, and dorsiflexion, takes place at the subtalar, transverse tarsal, cuboideonavicular, cuneonavicular, intercuneiform, cuneocuboid, tarsometatarsal, and intermetatarsal joints. Place one hand over the distal lateral and posterior aspect of the leg to stabilize the tibia and fibula and prevent movement at the knee and hip. Place your hand under the distal plantar aspect of the foot with your thumb on the first metatarsal and the other four fingers around the fifth metatarsal. Turn the foot in a lateral and superior direction. The normal end feel is abrupt and firm (ligamentous) (Kaltenborn, 1999; Magee, 1997) because of the tension in the joint capsules and the medial ligaments. The normal range of motion is 0–15 degrees (Figure 13.50) (American Academy of Orthopedic Surgeons, 1965).

Subtalar (Hindfoot) Inversion

Place the patient in the prone position with the foot over the end of the treatment table. Make sure that the hip is at 0 degrees of flexion–extension, abduction– adduction, and rotation, and that the knee is at 0 degrees

of extension. Place one hand over the middle posterior aspect of the leg to stabilize the tibia and fibula and prevent motion in the hip and knee. Place your other hand on the plantar surface of the calcaneus, grasping it between your index finger and thumb. Rotate the calcaneus in a medial direction. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsule and the lateral ligaments (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–5 degrees (Figure 13.51) (American Academy of Orthopedic Surgeons, 1965).

Subtalar (Hindfoot) Eversion

Place the patient in the prone position with the foot over the end of the treatment table. Make sure that the hip is at 0 degree of flexion–extension, abduction– adduction, and rotation, and that the knee is at 0 degree of extension. Place one hand over the middle posterior aspect of the leg to stabilize the tibia and fibula and prevent motion in the hip and knee. Place your other hand on the plantar surface of the calcaneus, grasping it between your index finger and thumb. Rotate the calcaneus in a lateral direction. The normal end feel is abrupt and firm (ligamentous) because of the tension in the joint capsule and the medial ligaments